Intensive insulin-adherence interventions that target type 2 diabetes patients with high risk of noncompliance can be beneficial.
Among patients with type 2 diabetes, poor medication adherence remains the main reason for adverse outcomes and increased costs. Within all antidiabetic therapies, insulin therapy appears to be among the most non-complied drugs due to the anxiety that comes from administration (self-injection) and fear of hypoglycemia. While there are many complicated obstacles to optimal medication use, interventions intended to improve medication compliance are often simple and only somewhat effective. Successfully targeting medication compliance, particularly for those patients who would benefit the most, may potentially lead to the therapy improvement, but so far this proposition has not been sufficiently assessed.
A study published in JAMA, March, 2019, evaluated the effectiveness of giving resources to help medication adherence to a subgroup of type 2 diabetes patients who benefit the most, versus helping all patients with type 2 diabetes to a smaller degree. This study proposes that with a limited set of resources, hospitals and practitioners should try to target high intensity interventions to those needing it the most, predominantly based on disease control and foreseeable risk of nonadherence. This type of approach seems to be more effective than general untargeted approaches.
This study was a randomized clinical trial. Data pooled for this study was gathered from the main health insurer in New Jersey, called Horizon. A total of 6,000 individuals with type 2 diabetes, over the age of 18, on basal insulin therapy were included in this trial. Patients who were insured through Medicaid or Medicare or those who were insured less than 3 months of continuous enrollment, were excluded. The study was conducted from July 7, 2016, through October 5, 2017. Participants were randomly assigned into 3 arms in a 1:1:1 ratio. Randomization was performed based on availability of 1 or more HbA1c test values available at baseline. Insulin use persistence was considered as the primary outcome. In terms of secondary outcomes, average changes in HbA1c level and health care utilization were evaluated. Outcomes were compared in moderate-intensity and high-intensity arms versus the low-intensity arm.
In this study, pharmacists interacting with patients and those patients were not blinded. However, the investigators remained blinded until all data analyses were finalized. The first study arm consisted of participants on low-intensity intervention which was defined as a personalized telephone consultation with a clinical pharmacist and two follow-up calls. All individuals in this arm received the low-intensity intervention. In the second group, 60% of participants who were considered at greater risk of noncompliance, received two calls from their primary care or clinical pharmacist to answer their questions and up to six follow-up calls. This intervention was considered moderate-intensity intervention. Additionally, the moderate-intensity intervention arm was offered to receive a weekly text messaging program which focused on medication-taking behaviors, lifestyle modification, and glycemic control. In the third study arm, 40% of patients with baseline Hb1C of 8% or higher and at high risk of noncompliance, received what was considered high-intensity intervention. This intervention was defined as a maximum of 12 follow-up calls, as well as phone calls to primary care clinicians or pharmacies as often as necessary.
The study results show that there was no significant difference for the moderate- or high-intensity arms compared with the low-intensity arm regarding insulin use persistence. A total of 24.7% of those in the low-intensity group, 30.7% in the medium-intensity group, and 34.3% in the high-intensity group completed the telephone consultation with a pharmacist. However, the high-intensity group appeared to experience the greatest improvements in glycemic control (difference from baseline in absolute HbA1c –0.25%) when compared with the low- and moderate-intensity arms (–0.15% for both arms). Furthermore, total cost and office visits were similar in all arms, although the moderate-intensity intervention arm had more hospitalizations (odds ratio, 1.22; 95% CI, 1.06-1.41) and emergency department visits (odds ratio, 1.38; 95% CI, 1.24-1.53) in comparison to low-intensity intervention arm. This study concluded that improvement in glycemic control was the goal, even though it was measured as the secondary outcome, and it is considered to a more important outcome in diabetes care.
- A total of 24.7% of those in the low-intensity group, 30.7% in the medium-intensity group, and 34.3% in the high-intensity group completed the telephone consultation with a pharmacist.
- Baseline persistence was high in all 3 arms.
- Targeting a different patient population might have increased the effectiveness of the interventions.
Lauffenburger JC, Lewey J, Jan S, et al. Effectiveness of Targeted Insulin-Adherence Interventions for Glycemic Control Using Predictive Analytics Among Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA Netw Open. 2019;2(3):e190657. doi:10.1001/jamanetworkopen.2019.0657
Ghazal Blair, Pharm.D. Candidate 2019, LECOM School of Pharmacy